Owner's Name_______________________________________________Phone_____________________

Name of Pet_____________________________________ [   ]Dog  [   ]Cat  [   ]Other________________

Breed______________________________________ Color_________________Birthdate_____________

                                                 [   ]Male    [   ]Neutered           [   ]Female    [   ]Spayed

I am the owner or agent of the pet described above, and have the authority to execute this consent.

I authorize the above-named veterinarian and his/her staff to perform the treatment/procedure(s) described below.  I have been informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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I understand that there are certain risks to anesthesia that could involve serious bodily injury or death and that these risks are present in any procedure that requires a general or intravenous anesthetic.  I consent to the use of anesthesia.

I understand that unforeseen conditions may require an extension of a planned procedure or operation.  I hereby authorize the performance of such procedures or operations as are necessary and advisable in the professional judgement of the veterinarian.

I have read and understand this consent form.  I realize that results cannot be guaranteed.  I consent to the proposed treatment/procedures.

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                               Signature of Owner/Agent                                                       Date